• Inpatient vs. outpatient surgeries

    Here’s another interesting figure from the American Hospital Association’s (AHA’s) Trends Affecting Hospitals and Health Systems.

    I knew that the majority of surgeries used to be inpatient and that that changed in the 1990s. What I did not appreciate, and this graph shows, is that the inpatient/outpatient breakdown has been constant since 1999. Why did the 1990s trend toward more outpatient surgeries stop completely?

    I’m tempted to pin it on the big change in the late 1990s, the backlash against managed care. What’s the mechanism exactly? Is it that insurers had weakened bargaining power with respect to hospitals once they could no longer sell tight networks? Hospitals and the provider system in general had less incentive to keep prices low (outpatient costing less than inpatient) in order to get into insurer networks.

    Or does something else explain this? Is it technology? Perhaps the tools that helped move surgeries from inpatient to outpatient stopped improving? If so, why?

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    • The post raises fascinating questions. Forgive me if I pose them as a medical (and economic) layman.

      Was the move to inpatient surgeries a result of better technology, or a simple change in conventional wisdom? Shortening stays after childbirth, for example, made both medical and financial common sense. Not the result of any ground-breaking new technology…true?

      Were the new kinds of surgery popularised in the 90s likely to be outpatient-friendly? Did the boom in laser eyesight correction and cosmetic procedures expand the surgery market, and hence account for a greater share of the total, until the trend levelled off? Are such “doctor’s office” procedures even counted in the total?

      Is the population aging, and hence more likely to require major (and hence inpatient) treatment? Are the new kinds of surgery which new technologies enable actually more complex, and likely to require longer operations, and recovery periods? Are transplants and major trauma becoming more commonplace?

      I suspect it doesn’t make medical common sense to increase the number of outpatient surgeries. Unless we can make bodies metabolise faster, the effects of anaesthesia won’t wear off any quicker. That means most CKO surgery will require a stay of several hours, and probably overnight, at least.

      I suspect, too, that surgery of any kind is a last resort for patients, doctors and insurers. Little of it is discretionary, and thus not highly responsive to financial encouragements. Not surprising that the point of diminishing returns for day-surgery was reached fairly quickly.

      • @headbang8 – Fantastic set of questions. As I hoped was clear in my post, explaining all this is beyond me at the moment. Hopefully someone more knowledgeable chimes in via comment.

    • Candidates for outpatient surgery are determined by risks inherent to the patient and risks inherent to the surgery. Recovery time and pain control after the surgery are also limiting factors.

      Short surgeries with low risk of blood loss are usually ideal. However, if the patient is sick enough, even some of those are better off in an inpatient setting. A laparoscopic tubal on an average weight healthy 25 y/o is different than the same procedure on a 450 pound 38 y/o with severe COPD and heart disease.

      I think that we have already moved out to the surgicenters all of the cases that fit there without difficulty. We will need some changes in technology to move many more, or better risk stratification plus more flexible schedules. The financial incentives are still there, especially for surgeons, to move cases out of the hospital. (The economic tensions between surgeons, surgicenters and anesthesia providers are significant.) The current trend is actually to move cases into the office when possible. Office based surgery is not well regulated in many states. There is significant controversy over its safety, though it is difficult to determine since reporting is not well done.

      http://archderm.ama-assn.org/cgi/reprint/140/11/1379.pdf

      Lastly, many new procedures we have seen recently are more invasive, things like functional neurosurgery. The trend has been to move procedures from the inpatient setting to the outpatient as they become safer, rather than develop procedures aimed just at outpatients. The boom in joint replacements has also kept inpatient numbers up.

      Steve

    • One thing I would be interested in seeing/knowing: are there differences in the inpatient v. outpatient surgery proportions by the type/size of hospital? Put another way, if you remove large health systems, would the proportion of surgeries inpatient v. outpatient look the same? I honestly have no idea.

    • sometimes it is not helpful to look at macro charts because underlying context variation makes generalizations untenable

      i am on medicare and medicare is a large factor in the economics of inpatient and outpatient surgery

      i recently had a catherization on an outpatient basis

      later i learned that my co-pay (part b) would have been less costly to me if it had been an inpatient procedure (part a)

      are outpatient rates higher than inpatient rates? generally or depending upon the procedure?

      is inpatient vs outpatient a cost efficiency issue which benefits the patient or part a vs part b revenues issue which benefits the provider